Basic Information
| Provider Information | |||||||||
| NPI: | 1851713358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | PHONG | ||||||||
| MiddleName: | TRUONG | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635205200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14655 GALAXIE AVE | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551248602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524326161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2014 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 11521 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.